Over-utilization of emergency room services and healthcare costs

¶ … Health Policy Economics class. Master Degree level. It 8-12 pages long 10 resources. The topic Over-Utilization Emergency Room Services. I uploading project details.

Reliance on emergency departments for non-emergent services has been on the increase with many people visiting them since they provide timely access to primary care. The 1985 Emergency Medical Treatment and Active Labor Act (EMTALA) mandated Medicare institutions to provide emergency departments for patients despite their regardless of their ability to pay for these services. Many of the uninsured or underinsured thus find these emergency rooms as the most convenience sources of health care. Overutilization of emergency rooms is a vicious cycle as a result of increasing health care costs that are associated with this phenomenon. Three possible solutions to this problem are identified which are health care homes, retail clinics and telehealth with the best solution being the health care homes.

Overutilization of emergency room services

Problem statement

Overutilization of emergency room services is one of the major causes of the increase in healthcare costs. This increase comes majorly as a result of majority of the patients seen in emergency rooms being recipients of Medicaid which is used for non-emergent purposes. Overutilization of emergency rooms has had a major impact on reforms in health care legislation and has brought about a huge debate for scholars of health and economics since health is a fundamental right for all human beings and decreasing the cost of health care is a priority for the government. There is also a vicious cycle in the overutilization of emergency room services since as more people become unable to access primary health care services, more of them are turning to these emergency department for care which is not urgent which continues to increase the cost for the emergency departments. The increase in cost of health care leads to majority of the population which is either uninsured or underinsured continuing to experience problems in paying for these high costs which creates this vicious cycle and negatively impacts the ability of these emergency departments to provide their services.

Major reasons for overutilization of emergency room services

Emergency room visits are on the rise as a result of reduced inpatient capacity in major hospitals as well as impaired flow of patients. The National Center for Health Statistics states that in the year 2004, there was an 18% increase in the number of emergency department visits over the previous 10-year period while at the same time hospitals experienced a 12.4% decrease in the number of hospital emergency departments. The Institute of Medicine also adds that visits to emergency departments grew more than twice as fast as the growth in population between the years 1993 and 2003 which caused more than 60% of the hospitals offering emergency room services to run at or over their capacity.

Increase in chronically ill or elderly citizens is one of the major factors contributing to the rise in emergency room visits. The second factor as identified by Thibadoux, Scheidt, and Luckey (2007)

is overworking or lack of physicians providing primary care. This is also coupled with the lack of primary care outside the normal business hours of any facility. As a result of their being few physicians providing primary care, there are longer wait times for appointments with physicians which has pushed majority towards emergency rooms. Tanne (2007)

also argues that high use of emergency rooms for problems that are not urgent is also driven by habit and preference. Lowe et al. (2005)

also adds that statistics of those receiving outpatient services in emergency rooms do not show any differentiation in the income, insurance, race or ethnicity of the users.

Privately insured people also contribute to increased emergency room visits. This is because they account for half of the increase in these visits as they continue to make fewer visits to primary care physicians. In the study conducted by Grieb and Clark (2008)

, it was found that 17.5% of all visits for ambulatory care were by beneficiaries of Medicaid which was compared to 7.6% of the privately insured. This has since risen to 25% for the uninsured, 50% for Medicaid beneficiaries and 75% for the privately insured. Overall, the lack of primary care providers is the leading cause of increase in utilization of emergency rooms services.

Are these increased visits to emergency rooms avoidable?

Bristol (2006)

argues that about 35% of all visits to emergency rooms are avoidable since they are ambulatory care sensitive (ACS) or non-urgent which makes them treatable in primary care hospitals. However, Blackstone, Buck, and Simon (2007)

argues that the percentage of avoidable visits is even higher. Studies by the National Center for Health Statistics show that 55% of all visits to emergency rooms are avoidable and two further studies conducted in Utah found that 44% of all visits to emergency rooms were primary care sensitive and roughly 40 -- 60% of all visits to emergency departments made by children were non-urgent. Beneficiaries of Medicaid and the uninsured form the majority of these avoidable visits.

High costs of avoidable visits to emergency rooms

Brailsford, Lattimer, Tarnaras, and Turnbull (2004)

argues that emergency room services are more costly than primary care services because they charge about two to five times what is charged for typical visits to private physicians. The National Association of Community Health Centers argues that over 18 billion dollars are wasted each year for visits to emergency rooms that are avoidable as a result of being treatable in non-urgent or primary care settings. This figure is calculated on the assumption that 35% of all visits to emergency rooms are avoidable, by far a conservative estimate. Furthermore, overutilization of emergency rooms drives health care costs high and also decreases the quality of care significantly. As the overcrowding of emergency rooms causes increase in health care costs for the providers, many are switching off their emergency departments since they are becoming too expensive to run. Moreover, as waiting times in emergency rooms are increasing, the patient perceptions of emergency room health care quality are decreasing which threatens the future of health care departments.

Possible solutions

1. Health care homes

Health care homes are possible solutions to the crisis facing emergency rooms as a result of their overutilization. A health care home is a practice which is home-based rather than the more common institutional-based care. Here, the patient receives majority of their health care in a manner that is continuous, regular and patient-centered which improves their health outcomes and helps to keep the cost of health care sufficiently low. By providing patients with a health care home, they are less likely to suffer from a costlier illness later in life and this decreases their chances of going to emergency rooms to receive health care.

2. Retail clinics

Retail or walk-in health clinics, also known as convenience care clinics, are usually located in pharmacies and drug stores can also help to reduce the utilization of emergency rooms. As studied by Gupta and Wang (2008)

, these retail clinics cost roughly one-fifth of an emergency room visit and it is estimated that 10% of all emergency room visits can be provided with adequate care by retail clinic staff. Another study identified the retail clinic as a solution for simple acute care for many of those who may visit emergency rooms. On the negative, retail clinics have been seen to eliminate the traditional physician-patient relationship since a study found that out of 125,000 visitors to retail clinics, less than 10% were willing to visit a hospital or emergency department Charatan, 2008()

3. Telehealth

Telehealth provides patients with 24-hour access to physician services via the use of telephones which helps to reduce the number of avoidable visits to emergency rooms from 41% to just 8%. Telehealth involves telephone consultation services coupled with telephone triage services where nurses operate triage programs to provide patients with prompt medical advice. The latter has been seen to reduce utilization of emergency rooms by more than 4% and has saved more than 400,000 dollars for emergency departments. Telehealth has, however, been criticized to lead to a significant increase in the mortality rate of patients as a result of their reliance on these services for chronic conditions.

Solution and its implementation

Health care homes are the chosen solution for this problem. For the solution to be a success, as the access to health care homes is expanded, patients should also be provided with increased access to health insurance. Studies in this field have shown that though health care homes may increase access to primary care thus leading to decreased utilization of emergency rooms, for it to make a greater impact on health care costs, it should be coupled with increased insurance coverage. This should be designed as a gradual process whereby additional homes are added gradually as the progress is evaluated. Additionally, in the implementation, two types of health care homes should be set up. The first is the primary care chronic conditions healthcare home which comprises of federally qualified health centers that receive federal aid and grants, rural health centers and physician practices. The second group is the community mental health center healthcare home which comprises of community mental health centers and their affiliates. This group will address behavioral health needs that address medical problems facing the patients such as schizophrenia that may cause other conditions such as cardiovascular and pulmonary complications and other infectious diseases. This is the implementation that was chosen for Missouri which is the first state to implement health care homes.

Health care homes should be staffed with allied professionals and other paraprofessionals such as physician assistants, medical technicians and nurse practitioners since it is difficult to ensure the availability of primary care physicians for these health care homes. They should also be coupled with strategies such as wellness, health education and prevention measures for the treatment and rehabilitation of patients.

Justification

Health care homes are bound to be successful in increasing access to primary health care for patients thus reducing the utilization of emergency rooms since they provide patients with a usual source of health care despite inequitable distribution of primary care physicians. These health care homes also include programs that redirect Medicaid spending to appropriate primary care providers instead of emergency departments which also significantly reduces spending on Medicaid reimbursement. This will create an avenue for the Medicaid program to encourage more people to join the programs as a result of the creation of a more efficient health care delivery system which greatly reduces the loss of Medicaid revenue. Medicaid savings will also come from improved health outcomes for patients as a result of fewer hospitalizations and visits to specialists. Olson (2010)

argues that regular users of health care homes visit emergency departments for emergent reasons 50% fewer times than nonusers.